Diabetes quality management in care groups and outpatient clinics

Abstract

This research project relates to diabetes quality management in Dutch care groups (40-200 GP practices) and outpatient clinics. Improvement of quality management at an organisational level on top of the existing quality management in separate general practices is expected to be associated with better outcomes in diabetes care. Quality management was measured with newly developed questionnaires about organisation of care, multidisciplinary teamwork, patient centeredness, performance results, quality improvement policy and management strategies (six domains, score range 0-100%), filled out by quality managers. Based on their scores, responders received feedback and a benchmark (to compare themselves to similar organisations); they were granted access to a toolbox with quality improvement instruments. If requested, additional support in improving quality management was available, consisting of an elucidating phone call or a visit of an experienced consultant. After a year, the level of quality management was measured again. Besides, we focused on patient centeredness and the changes in this particular domain, as more focus on patient centeredness diabetes care leads to an increasing need for quality management on patient centeredness at organisational level as well. We also explored the association between quality management in a subsample of care groups and six of their aggregate performance indicators on glycated haemoglobin, lipid profile, and systolic blood pressure. Of the initially 60 participating care groups 51 completed the study. Their total quality management score improved from 60% at baseline to 65% after the intervention at one year (62.8-67.5%; p<0.0001). All six above mentioned domains also improved significantly, according to our analyses probably due to the feedback and benchmark. Of the 44 participating outpatient clinics 28 completed the study. Their total quality management score changed from 66% to 67% (non-significant). Only the results in the domain ‘multidisciplinary teamwork’ improved. Focussing on patient centeredness, care groups improved significantly on this domain (from 47% to 53%), and on its sub-domains ‘access to medical files’, and ‘safeguarding patients’ interests’. Outpatient clinics, which scored higher at baseline (67%) than care groups, did not improve on patient centeredness or its sub-domains. ‘Formal patient involvement’ remained low in both care groups (23%) and outpatient clinics (34%). Quality management on patient centeredness was not significantly associated with a particular step of our intervention. The exploratory study on the association between quality management of care groups and performance indicators could not demonstrate an association between their quality management and aggregated performance indicators. Only the domain ‘management strategies’ was positively associated with the percentage of patients achieving an HbA1c < 53 mmol/mol.

Conclusions:

Our questionnaires can measure (changes in) diabetes quality management; feedback and a benchmark are likely to improve diabetes quality management in care groups. In outpatient clinics, quality management improvement probably needs other incentives than in care groups. Interventions to improve quality management on patient centeredness in diabetes care organizations should differ between primary and secondary care. Before we can draw conclusions on the impact of quality management on care group level, the association between quality management and performance indicators needs further studying.